Provider First Line Business Practice Location Address:
1508 W CAYUSE CREEK DR
Provider Second Line Business Practice Location Address:
STE 150
Provider Business Practice Location Address City Name:
MERIDIAN
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83646
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-888-0900
Provider Business Practice Location Address Fax Number:
208-888-0950
Provider Enumeration Date:
07/17/2007